Comparison of 2-octyl cyanoacrylate and n-octyl cyanoacrylate topical skin adhesives for wound closure after ankle fracture surgery: a prospective randomized trial.

To date, only a few clinical studies have investigated the differences between 2-octyl cyanoacrylate and n-octyl cyanoacrylate topical skin adhesives (TSAs). This study aimed to compare the outcomes of the two TSAs for wound closure after ankle fracture surgeries. Fifty-six patients were randomized to receive either a 2-octyl or n-octyl cyanoacrylate TSA. At 3 and 6 months after surgery, wound cosmetic outcomes were assessed using the Hollander Wound Evaluation Scale (HWES), and patient satisfaction for wound cosmesis was assessed using the visual analog scale (VAS) and 5-item Likert scale. Functional outcomes at 6 months after surgery were assessed using the Olerud-Molander Ankle Score (OMAS). Fifty-five patients completed the study protocol. Within the follow-up period, no differences were found between the two groups in terms of HWES, VAS, 5-item Likert scale, and OMAS. 2-octyl cyanoacrylate TSA and n-octyl cyanoacrylate TSA were comparable options for wound closure after ankle fracture surgeries in terms of wound cosmesis, patient satisfaction, and functional outcome.

Value of postoperative computed tomography for the diagnosis of lateral hinge fracture in medial opening-wedge supramalleolar osteotomy.

INTRODUCTION: It remains unclear whether computed tomography (CT) is superior to plain radiography in detecting lateral hinge fractures after medial opening-wedge supramalleolar osteotomy (SMO) of the ankle joint. This study aimed to evaluate the disparity between postoperative plain radiography and CT in detecting lateral hinge fractures after medial opening-wedge SMO and to identify the predictive factors of lateral hinge fractures. MATERIALS AND METHODS: This retrospective study included 39 patients who underwent medial opening-wedge SMO. The immediate postoperative plain radiography and CT scan images were retrieved, and the presence of lateral hinge fractures was independently determined. Depending on the fracture gap, the lateral hinge fractures were subclassified as stable (gap < 2 mm) or unstable (gap ≥ 2 mm) fractures. To investigate the predictive factors, the cases were divided based on diagnostic tools such as plain radiography and CT. RESULTS: The incidence of lateral hinge fractures was 48.7% (19/39) on plain radiographs and 61.5% (24/39) on CT scans. Five cases of lateral hinge fractures additionally detected on CT scans were stable fractures, and all had been classified as no fracture on plain radiographs. The unstable fractures that had been subclassified based on plain radiographs did not change on CT scans. None of the variables were associated with the presence of lateral hinge fractures on plain radiographs and CT scans. CONCLUSIONS: Postoperative CT after medial opening-wedge SMO has no additional diagnostic value if the lateral hinge fracture has already been diagnosed on plain radiography. Therefore, postoperative CT is only recommended when lateral hinge fractures are not visible on plain radiographs.

Genetically defined individual reference ranges for tryptase limit unnecessary procedures and unmask myeloid neoplasms.

Serum tryptase is a biomarker used to aid in the identification of certain myeloid neoplasms, most notably systemic mastocytosis, where basal serum tryptase (BST) levels >20 ng/mL are a minor criterion for diagnosis. Although clonal myeloid neoplasms are rare, the common cause for elevated BST levels is the genetic trait hereditary α-tryptasemia (HαT) caused by increased germline TPSAB1 copy number. To date, the precise structural variation and mechanism(s) underlying elevated BST in HαT and the general clinical utility of tryptase genotyping, remain undefined. Through cloning, long-read sequencing, and assembling of the human tryptase locus from an individual with HαT, and validating our findings in vitro and in silico, we demonstrate that BST elevations arise from overexpression of replicated TPSAB1 loci encoding canonical α-tryptase protein owing to coinheritance of a linked overactive promoter element. Modeling BST levels based on TPSAB1 replication number, we generate new individualized clinical reference values for the upper limit of normal. Using this personalized laboratory medicine approach, we demonstrate the clinical utility of tryptase genotyping, finding that in the absence of HαT, BST levels >11.4 ng/mL frequently identify indolent clonal mast cell disease. Moreover, substantial BST elevations (eg, >100 ng/mL), which would ordinarily prompt bone marrow biopsy, can result from TPSAB1 replications alone and thus be within normal limits for certain individuals with HαT.

The Influence of Ankle Position on Radiographic Diagnosis of Acute Achilles Tendon Rupture.

No previous study has demonstrated the relationship between the ankle position and radiographic diagnosis of acute Achilles tendon rupture. The purpose of this study was to investigate the influence of ankle position in the presence of diagnostic radiographic signs in acute Achilles tendon rupture. A retrospective review of 154 ankle lateral radiographs of acute Achilles tendon rupture was performed. Ankle position was classified as dorsiflexion, neutral, or plantar flexion by measurement of the tibiotalar angle. Kager's triangle, Toygar's angle, Arner's sign, and thickening of the Achilles tendon were assessed as diagnostic radiographic signs, and their relations to ankle position were analyzed. Interobserver reliabilities of radiographic signs were moderate to substantial (kappa value, range 0.41-0.68). All 4 signs were significantly more visible in ankle plantar flexion than dorsiflexion. The presence of Toygar's angle and positive Arner's sign were significantly increased in ankle plantar flexion compared to neutral, while the presence of Kager's triangle, and thickening of the Achilles tendon did not differ according to ankle position. The diagnostic radiographic signs of acute Achilles tendon rupture were better presented in ankle plantar flexion position than neutral and dorsiflexion positions. Neutral and dorsiflexion ankle positions should be avoided when performing lateral radiographs of patients with suspected acute Achilles tendon rupture.

How accurately can surgeons perform angle manipulation? Quantitative assessment of the accuracy of manual angle manipulation of orthopedic surgery: a cadaver study.

INTRODUCTION: To date, only few studies have been performed on the accuracy of manual angle manipulation during orthopedic surgery. This cadaver study was aimed at quantitatively assessing the accuracy of manual angle manipulation performed by orthopedic surgeons according to their surgical experience and comparing it with manipulation performed with the assistance of a digital goniometer. MATERIALS AND METHODS: Six lower-leg specimens of fresh-frozen human cadavers were subjected to angle manipulation performed via Kirschner wire (K-wire) insertion. K-wires were inserted manually and with the assistance of a digital goniometer at target angles of 0°, 30°, and 60° by three operators who had different levels of experience in orthopedic surgery. The accuracy of the insertion angles at the target angles was evaluated using computed tomography. RESULTS: The mean angle error in the manual angle manipulation was 8.8° (standard deviation [SD] 6.0). When the target angles were set to 0°, 30°, and 60°, the identified angle errors were 6.1° (SD 4.3), 8.8° (SD 6.6), and 11.7° (SD 5.6), respectively, and each value did not show any significant difference among the operators. With the assistance of a digital goniometer, the mean (SD) angle error was significantly improved to 2.1° (1.1°) (p < 0.001). The amount of improvement in accuracy significantly increased as the target angle increased (p = 0.01). CONCLUSION: This cadaver study quantified the inaccuracy of manual angle manipulation in orthopedic surgery and showed that these inaccuracies ​​can be improved using an assistive device. These results support the need to develop a device that can compensate manual angle manipulation in orthopedic surgery.

Risk Factors for Persistent Pain Requiring Surgical Treatment in Adult Symptomatic Accessory Navicular.

OBJECTIVE: Identifying the risk factors for persistent pain despite proper conservative treatment in adult symptomatic accessory navicular may reduce the need for surgical treatment. The aim of this study was to identify any such risk factors. DESIGN: Cohort study. SETTING: University hospital foot and ankle clinic. PATIENTS: A retrospective review of 313 patients who presented with adult symptomatic accessory navicular was performed. ASSESSMENT OF RISK FACTORS: Potential risk factors were identified via medical records and foot radiographs. The possible risk factors included age, gender, body mass index, smoking status, occurrence/cause of symptoms, occupation, type of accessory navicular, and radiographic foot parameters. MAIN OUTCOME MEASURES: Predictors that relate to persistent pain requiring surgical treatment in adult accessory navicular were analyzed using logistic regression analysis. RESULTS: Of the 313 patients included, 30 (9.6%) underwent surgical treatment due to failure of conservative treatment. The odds of needing surgical treatment decreased by 0.96 per year of age at symptom onset (P = 0.030), but those odds were 8.52 times higher in patients who had a type IIB accessory navicular (P = 0.001). Other variables did not reach statistical significance. CONCLUSIONS: Younger age at symptom onset and type IIB were the risk factors for persistent pain requiring surgical treatment in adult symptomatic accessory navicular.

Comparison between headless compression screws and tension band wires for the fixation of medial malleolar fractures: a prospective randomized trial.

INTRODUCTION: To date, there has been no prospective randomized trial supporting the rationale of the use of headless compression screw (HCS) compared to conventional fixation methods for medial malleolar fractures. This study aimed to prospectively compare the outcomes of the HCS and tension band wire (TBW) for the fixation of medial malleolar fractures. MATERIAL AND METHODS: Sixty patients were randomized to receive either an HCS or a TBW for the fixation of a medial malleolar fracture. Clinical outcomes were assessed using the Olerud-Molander ankle score (OMAS), EuroQoL five-dimensional instrument (EQ-5D) score, visual analog scale (VAS) score, patient satisfaction with implant-related symptoms, operative time, and incision length. Radiographic outcomes were assessed using the presence of nonunion, delayed union, and articular incongruity. Clinical and radiographic assessments were performed at 2 and 6 weeks and 3, 6, and 12 months postoperatively. RESULTS: The OMAS, EQ-5D score, VAS score, and operative time did not differ between the HCS and TBW groups; however, the HCS group had greater satisfaction with implant-related symptoms and smaller incision than the TBW group. There was no difference in the presence of nonunion, delayed union, and articular incongruity. CONCLUSION: HCS fixation for medial malleolar fractures is not inferior to TBW fixation, while reducing implant-related symptoms. These findings suggest that HCS is a viable alternative for the fixation of medial malleolar fractures.

Learning curve of the Krackow suture technique for the repair of Achilles tendon rupture.

INTRODUCTION: Knowledge on the learning curve for the repair of Achilles tendon rupture is limited. The aim of this study was to quantify the learning curve for the Krackow suture technique for the repair of Achilles tendon rupture and to identify the correlation between the cumulative volume of cases and clinical outcome measures. MATERIALS AND METHODS: A total of 226 cases of Achilles tendon repair using the Krackow suture technique were reviewed. Each surgery was independently performed by four surgeons who started a foot and ankle specialty career after fellowship training. After logarithmic transformation of the operative time and cumulative volume of cases, a linear regression analysis was performed to determine the best-fit linear equations to predict the required time for the Krackow suture technique according to the cumulative volume of cases. The correlation between the cumulative volume of cases and clinical outcome measures was analyzed using Pearson correlation coefficients. Receiver operating characteristic curves were constructed to determine the minimum number of cases with an operative time shorter than the average in the first 30 cases. RESULTS: In all four surgeons, significant log-linear correlations were observed between the operative time and cumulative volume of cases. The best-fit linear equations showed estimated learning rates of 90%, 87%, 92%, and 86% for each of the four surgeons, indicating that the necessary operative time decreased by 10%, 13%, 8%, and 14%, respectively, when the cumulative volume of cases had doubled. The minimum number of cases with an operative time shorter than the average was 9 (91% sensitivity and 59% specificity). The clinical outcome measures at 6 and 12 months postoperatively were available for one surgeon; however, no correlation was found with the cumulative volume of cases. CONCLUSION: The learning rate for the Krackow suture technique for the repair of Achilles tendon rupture was approximately 89%, indicating that the required operative time can decrease by up to 11% when the cumulative volume of cases doubles. Therefore, it is important to rapidly accumulate surgical experience during the early phase of training.

Clinical Impact of Metabolic Syndrome on Eccentric Exercises for Chronic Insertional Achilles Tendinopathy.

Metabolic syndrome is one factor known to contribute to the development of tendinopathies. The aim of this study was to compare the clinical outcomes of eccentric calf-muscle exercise for treatment of chronic insertional Achilles tendinopathy in patients with or without metabolic syndrome. Twenty-eight patients with chronic insertional Achilles tendinopathy and metabolic syndrome who performed eccentric calf-muscle exercise were retrospectively compared with 28 age- and sex-matched controls without metabolic syndrome. Comparisons between the 2 groups were made by evaluating the Visual Analog Scale for pain, patient satisfaction, and amount of pain medications needed during 3 months of follow-up. Two-way analysis of variance with repeated measures showed that the pain scales in the metabolic syndrome group were higher than those in the control group during the follow-up period (F[1,54] = 24.45, p < .001). The patient satisfaction ratings were lower and the amount of required pain medication was higher in the metabolic syndrome group (p < .001 and p < .001, respectively). Eccentric calf-muscle exercises for chronic insertional Achilles tendinopathy were less effective in patients with metabolic syndrome. Therefore, these patients should be managed with a combination of other treatment modalities rather than eccentric exercise alone.

Assessment of Osteoporosis and Fracture Risk in Mastocytosis within a North American Cohort.

BACKGROUND: Systemic mastocytosis (SM), a clonal expansion of mast cells affecting multiple organs including the skeletal system, puts patients at risk for osteoporosis and fractures. Various aspects of skeletal disease in SM have been reported among European cohorts. OBJECTIVE: To determine fracture prevalence and risk predictors in SM in a North American (NA) cohort and compare findings with studies of other populations. METHODS: Fifty patients, aged 25-74 years, were grouped based on fracture type and history. Data collected included laboratory findings and radiographic markers such as serum tryptase, bone turnover markers, dual-energy x-ray absorptiometry images, and trabecular bone scores. We performed univariate and multivariate analyses of these findings. RESULTS: Fracture history was found in 74% of patients. Significantly different median age, body mass index, dual-energy x-ray absorptiometry scores, and alkaline phosphatase levels were observed between fracture groups, consistent with French and Dutch studies. Significant findings included the difference in trabecular bone scores among fracture groups, the association between alkaline phosphatase and fracture type and occurrence, and the model for predicting fracture risk based on DXA spine T-scores, alkaline phosphatase, and age (81.3% accuracy and 77.1% sensitivity). CONCLUSIONS: Our findings in an NA cohort are in overall agreement with those reported in European studies of skeletal disease and fracture risk for individuals with SM. We include an interactive calculator designed from a predictive model based on the NA cohort, which may be used for improved screening for fracture risk.

Association of Ankle Dorsiflexion With Plantar Fasciitis.

This study aimed to compare the mean ankle dorsiflexion range between individuals with and without plantar fasciitis using passive ankle dorsiflexion with consistent pressure, and to identify the prevalence of an isolated gastrocnemius and gastrocnemius soleus complex contracture in 2 groups. 91 participants were prospectively classified into the plantar fasciitis group (45 subjects) and the control group (46 subjects). Ankle dorsiflexion was measured with the knee extended and with the knee flexed 90° using a standard orthopedic goniometer while a consistent force of 2 kg was applied under the plantar surface of the forefoot using a custom-made scale. Intraclass correlation coefficients (ICC) were calculated to determine the interobserver and intraobserver reliability of the current ankle dorsiflexion measurement. The current ankle dorsiflexion measurement revealed excellent interobserver and intraobserver reliability. The mean ankle dorsiflexion in the knee extended was -9.6° ± 8.1° and -11.2° ± 8.2° in the study and control groups, respectively (p = .353). The mean ankle dorsiflexion in the knee flexed was 7.8° ± 6.5° and 5.1° ± 7.4° in the study and control groups, respectively (p = .068). In the study and control groups, 68.9% and 65.2%, respectively, had an isolated gastrocnemius contracture and 24.4% and 30.4%, respectively, had a gastrocnemius-soleus complex contracture (p = .768). The present study demonstrated that there were no significant differences in passive ankle dorsiflexion and in the prevalence of an isolated gastrocnemius or gastrocnemius soleus complex contracture between individuals with and without plantar fasciitis.

Routine KIT p.D816V screening identifies clonal mast cell disease in patients with Hymenoptera allergy regularly missed using baseline tryptase levels alone.

BACKGROUND: Clonal mast cell disorders and elevated basal serum tryptase (BST) levels with unknown cause(s) are associated with severe Hymenoptera venom-triggered anaphylaxis (HVA). However, some individuals with clonal disease have a normal BST level (<11.4 ng/mL). OBJECTIVE: Our aim was to evaluate whether screening for KIT p.D816V in the blood is a useful clinical tool to risk-stratify patients with venom allergy. METHODS: We prospectively recruited 374 patients with Hymenoptera allergy and no overt signs of mastocytosis who were referred to our center during the years 2018 and 2019. KIT p.D816V was determined in their peripheral blood by quantitative PCR, and tryptase genotyping was performed by droplet digital PCR. RESULTS: In all, 351 patients (93.9%) had normal levels of BST, and KIT p.D816V was detected in 8% of patients (28 of 351), predominantly in patients with the most severe Mueller grade IV anaphylaxis (18.2% [24 of 132] vs 1.8% in patients with lower grades [4 of 88 with grade III and 0 of 131 with other grades]; P < .001). In grade IV patients with a normal BST level, KIT p.D816V was associated with more severe symptoms, including a significantly higher frequency of loss of consciousness (58.3% [14 of 24] vs 34.3% [37 of 108]; P = .03) and absence of skin symptoms (41.7% [10 of 24] vs 15.7% [17 of 108]; P = .004). Among patients with a normal BST level, KIT p.D816V (OR = 10.25 [95% CI = 3.75-36.14]; P < .0001) was the major risk factor associated with severe HVA. Hereditary α-tryptasemia (HαT) due to increased germline copies of TPSAB1 encoding α-tryptase was the most common cause (65.2% [15 of 23]) of elevated BST level in patients with HVA, and together with KIT p.D816V, it accounted for 90% of BST level elevations (20 of 23) in patients with HVA. CONCLUSION: These results indicate that routine KIT p.D816V screening identifies clonal disease in high-risk patients with HVA who are regularly missed when BST level is used alone.

Investigation of the Effect of Bone Mineral Density on the Postoperative Outcome of Ankle Fractures in Elderly Patients.

BACKGROUND: The association between ankle fractures in elderly patients and low bone mineral density (BMD) has recently been recognized, but the effect of BMD on the postoperative outcome of these fractures is unknown. The aim of this study was to investigate the effect of BMD on the postoperative outcome of ankle fractures in elderly patients to evaluate the need for BMD screening. METHODS: We retrospectively reviewed 48 patients aged 65 years or older who had ankle fractures and underwent dual-energy x-ray absorptiometry to assess BMD after surgical treatment of the fracture. Postoperative outcomes were assessed using the Olerud-Molander Ankle Score (OMAS), visual analog scale (VAS) score for pain, Kellgren and Lawrence (K&L) grading scale score, and quality of fracture reduction. The correlation between the BMD and the outcome measures at 12 months after surgery was analyzed using the Pearson correlation coefficient. RESULTS: The mean absolute value of BMD was 0.6 ± 0.1 g/cm2 (T-score, -1.5 ± 1.2) at the femoral neck and 0.8 ± 0.2 g/cm2 (T-score, -1.2 ± 1.5) at the lumbar spine. Osteoporosis was present in 33% of female patients and in 11% of male patients. At 12 months after surgery, the OMAS was 70 ± 17 and the VAS score for pain was 18 ± 17. Of the patients, 20, 21, 5, 1, and 1 had K&L grades of 0, 1, 2, 3, and 4, respectively. None of the clinical and radiographic outcome measures were correlated with the BMD values of the patients. CONCLUSION: The postoperative outcome of the ankle fractures in elderly patients at 12 months after surgery showed no correlation with femoral neck or lumbar spine BMD at the time of fracture. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Bone Defects After Surgery for Displaced Intraarticular Calcaneal Fractures Spontaneously Improve Without Bone Grafting.

BACKGROUND: Most intraarticular displaced calcaneal fractures are accompanied by bone defects after surgical treatment, but the concern about negative effects of bone defects has not been resolved yet owing to the few studies on this issue. Therefore, studies on volumetric changes in bone defects over time and the correlation between postoperative outcomes and residual bone defects will be helpful to address the controversy on the necessity of bone grafting in bone defects of calcaneal fractures. QUESTIONS/PURPOSES: (1) Do bone defects change in size in the first year after surgical treatment of displaced intraarticular calcaneal fractures? (2) Does the size of residual bone defects correlate with postoperative radiographic or clinical outcomes? METHODS: Between 2015 and 2019, 99 patients with displaced intraarticular calcaneal fractures visited the investigators' institution, of whom 95 received surgical treatment. Of the patients treated with surgery, 25% (24 of 95) did not undergo open reduction and internal fixation via an extensile lateral approach, and 19% (18 of 95) had multiple fractures, bilateral fractures, open fractures, or a history of previous surgery on the calcaneus; all of these patients were excluded. During the study period, CT was routinely performed for calcaneal fractures immediately after and 12 months after the surgery, but 6% (6 of 95) of the patients had insufficient CT data due to loss to follow-up before 12 months or other reasons, leaving 47 patients for evaluation in this retrospective study. Fractures were fixed with plate and screws, and bone grafting was not performed in all patients. To answer our first question, which was on the changes in bone defects over time, volumetric measurements of the bone defect were performed using CT via the ITK-SNAP software. The percentage of volumetric change was calculated as a fraction of the volumetric change over 12 months from the initial volume. The percentage of the residual bone defect was calculated as a fraction of the volume of the residual bone defect relative to the volume of the entire calcaneus. To answer our second question, which was on the correlation between residual bone defects and postoperative outcomes, we assessed the Böhler angle, Gissane angle, calcaneal height, Olerud-Molander Ankle Score (OMAS), and VAS score for pain and compared these parameters with the size of the residual bone defect using the Pearson correlation coefficient. The OMAS and VAS scores for pain were evaluated and recorded during patient visits, and we obtained the scores through a chart review. All volumetric measurements and radiographic evaluations were performed by two orthopaedic surgeons, and the intraobserver and interobserver reliability were assessed using the intraclass correlation coefficient. RESULTS: The mean volume of the bone defect measured using CT was 4 ± 3 cm3 immediately after surgery and 1 ± 1 cm3 12 months after surgery. During the first 12 months after surgery, the mean volume of the bone defect was reduced by 77% (95% confidence interval 73% to 80%). The mean residual bone defect in the entire calcaneus was 2% (95% CI 1% to 2%), and none of the postoperative outcomes were correlated with the residual bone defect. CONCLUSION: As bone defects substantially resolve without treatment, surgeons do not need to use bone graft for the surgical treatment of displaced intraarticular calcaneal fractures. Future studies that include patients who underwent bone grafting for the treatment of calcaneal fractures are needed to confirm our findings and to further investigate whether bone grafting has additional benefits for the recovery of bone defects. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison of the intraoperative efficacy of the powered rasp and conventional burr in arthroscopic resection of anterior ankle osteophytes.

BACKGROUND: The efficacy of the powered rasp, a new reciprocating motion device for arthroscopic resection of osteophytes, has not been verified. The aim of this study was to compare the intraoperative efficacy of the powered rasp in arthroscopic resection of anterior ankle osteophytes to that of the conventional burr. METHODS: A total of 49 consecutive patients who underwent arthroscopic resection of anterior ankle osteophytes (26 patients with the conventional burr and 23 patients with the powered rasp) were retrospectively reviewed. The preoperative volume of each osteophyte was measured using computerized tomography scan and three-dimensional software. The resection time was measured by review of the individual arthroscopy video, and the estimated resection rate was calculated as the volume of osteophytes/resection time. RESULTS: The preoperative volume of osteophytes was not different between the two groups (847.8 ± 685.3 mm3 in the conventional burr and 913.3 ± 605.8 mm3 in the powered rasp, p = 0.726). The resection time was 442.4 ± 216.6 s (seconds) in the conventional burr and 386.4 ± 186.3 s in the powered rasp, and the estimated resection rate was 1.8 ± 1.0 mm3/s with the conventional burr and 2.4 ± 1.3 mm3/s with the powered rasp. These measurements were not significantly different between the two groups (p = 0.340 and 0.083, respectively). CONCLUSION: The intraoperative efficacy of the powered rasp did not show superiority to that of the conventional burr in arthroscopic resection of anterior ankle osteophytes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of Outcome of Deltoid Ligament Repair According to Location of Suture Anchors in Rotational Ankle Fracture.

BACKGROUND: The suture anchors for the repair of deltoid ligament in rotational ankle fracture are inserted mostly into the medial malleolus, but sometimes are placed into the talus depending on the rupture site. This study sought to compare the radiological and clinical outcomes of deltoid ligament repair according to using these 2 locations for suture anchor placement. METHODS: The cases of 131 patients (114 patients with suture anchors on the medial malleolus and 17 patients with suture anchors on the talus) who underwent deltoid ligament repair along with ankle fracture fixation were retrospectively reviewed. Medial clear space oblique (MCSo), medial clear space perpendicular (MCSp), tibiofibular clear space (TFCS), and tibiofibular overlap (TFO) were measured as radiological outcomes, while the Olerud-Molander Ankle Score (OMAS) and visual analog scale (VAS) score for pain were calculated as clinical outcomes. The follow-up period did not differ between the 2 groups (16.8 ± 10.9 months in the medial malleolus group vs 17.9 ± 14.3 months in the talus group; P = .670). RESULTS: There were no differences in MCSo, MCSp, TFCS, and TFO at 3 months after surgery and final follow-up. The OMAS and VAS for pain did not show intergroup differences at final follow-up. CONCLUSION: The surgical outcome of deltoid ligament repair in rotational ankle fracture did not differ whether the suture anchors were inserted into the medial malleolus or into the talus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Relationship between Hallux Valgus and Pes Planus in Adult Patients.

This study aimed to determine whether the degree of pes planus was associated with hallux valgus severity and hallux valgus surgery outcomes. A total of 122 feet were retrospectively analyzed after hallux valgus surgery. The hallux valgus angle, inter-metatarsal angle, lateral talo-first metatarsal angle, calcaneal pitch, and talonavicular coverage angle were measured. The Foot and Ankle Outcome Score and Foot Function Index were evaluated. A significant correlation between radiographic parameters of pes planus and hallux valgus severity, radiographic outcomes, Foot and Ankle Outcome Score, and Foot Function Index were not noted. The hallux valgus angle and inter-metatarsal angle changed significantly after the surgery (p < .001 and p < .001, respectively); however, a significant difference was not noted between the pes planus and non-pes planus groups (p = .279 and p = .632, respectively). A significant interaction between the time points and groups was not observed with respect to the hallux valgus angle (p = .311) and inter-metatarsal angle (p = .417). Multivariable logistic regression revealed that none of the radiographic parameters for pes planus affected hallux valgus recurrence. Pes planus in adult patients is not significantly associated with hallux valgus severity and recurrence, radiographic outcomes, or clinical scores.

Necessity of Interfragmentary Lag Screws in Precontoured Lateral Locking Plate Fixation for Supination-External Rotation Lateral Malleolar Fractures.

BACKGROUND: Interfragmentary lag screws, protected by a plate, have been applied for many years in the treatment of supination-external rotation (SER) ankle fractures. Recently, similar biomechanical stability was found between fixation completed with a plate and lag screw and a plate alone. The aim of this study was to determine whether interfragmentary lag screws are necessary during precontoured lateral locking plate fixation for SER lateral malleolar fractures. METHODS: A prospective randomized controlled trial of 76 patients with unilateral Lauge-Hansen SER lateral malleolar fractures was conducted. The patients were randomly treated either with or without the use of interfragmentary lag screws with precontoured lateral locking plate fixation. Clinical outcomes were assessed using the Olerud-Molander Ankle Score and a visual analog scale for pain. Radiologic outcomes were assessed based on the Kellgren and Lawrence scale score, incongruity of the ankle joint, and type of fracture healing. Sixty-nine patients completed 12 months of follow-up. RESULTS: There was no significant difference between the 2 groups with regard to clinical outcomes at 3 and 12 months after surgery and radiologic outcomes at 12 months after surgery. All patients in both groups achieved primary bone healing. CONCLUSION: The results of this study suggest that with precontoured lateral locking plate fixation, the use of interfragmentary lag screw is not essential in the treatment SER lateral malleolar fractures. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Percutaneous Reduction and 2.7-mm Cortical Screw Fixation for Low-Energy Lisfranc Injuries.

To use the advantages of transarticular screw fixation while minimizing iatrogenic involved joint damage and screw irritation, it is important to determine the screw size. The aim of this study was to analyze the outcomes of percutaneous reduction and 2.7-mm cortical screw fixation for low-energy Lisfranc injuries and determine whether the procedure is a safe alternative to traditional screw fixation using a larger screw size. A review was performed for all patients who underwent percutaneous reduction and 2.7-mm cortical screw fixation for low-energy Lisfranc injuries at a single institution over a 6-year period. Thirty-one patients were enrolled in this study. Patients were assessed clinically and radiographically for demographics, foot function index (FFI), numerical rating scale (NRS) for pain, patient satisfaction, and complication rates. Factors affecting screw breakage and its clinical relevance were also analyzed. The FFI and NRS for pain were 17.2 ± 14.7 (range 0.8 to 57.8) and 3.1 ± 2.3 (range 0 to 8) points, respectively, at the 12-month follow-up visit. One patient (3.2%) underwent arthrodesis for the development of posttraumatic arthritis; all other patients recovered without sequelae. Screw breakage was identified in 7 patients (22.6%). There was no significant difference between patients with and without screw breakage in terms of FFI, NRS for pain, patient satisfaction, or complication rate. Body mass index (BMI) was significantly higher in patients with screw breakage than in those without screw breakage. Receiver operator characteristics curve analysis demonstrated a strong relationship between BMI and screw breakage (area under the curve = 90%, p < .001), and the potential BMI cutoff value was 27.8 kg/m2. After considering the incidence of screw breakage, percutaneous reduction and 2.7-mm cortical screw fixation can be a viable option for treating low-energy Lisfranc injuries in nonobese patients, especially those with BMI <27.8 kg/m2.

Dasatinib Inhibits Lyn and Fyn Src-Family Kinases in Mast Cells to Suppress Type I Hypersensitivity in Mice.

Mast cells (MCs) are systemically distributed and secrete several allergic mediators such as histamine and leukotrienes to cause type I hypersensitivity. Dasatinib is a type of anti-cancer agent and it has also been reported to inhibit human basophils. However, dasatinib has not been reported for its inhibitory effects on MCs or type I hypersensitivity in mice. In this study, we examined the inhibitory effect of dasatinib on MCs and MC-mediated allergic response in vitro and in vivo. in vitro, dasatinib inhibited the degranulation of MCs by antigen stimulation in a dose-dependent manner (IC50, ~34 nM for RBL-2H3 cells; ~52 nM for BMMCs) without any cytotoxicity. It also suppressed the secretion of inflammatory cytokines IL-4 and TNF-α by antigen stimulation. Furthermore, dasatinib inhibited MC-mediated passive cutaneous anaphylaxis (PCA) in mice (ED50, ~29 mg/kg). Notably, dasatinib significantly suppressed the degranulation of MCs in the ear tissue. As the mechanism of its effect, dasatinib inhibited the activation of Syk and Syk-mediated downstream signaling proteins, LAT, PLCγ1, and three typical MAP kinases (Erk1/2, JNK, and p38), which are essential for the activation of MCs. Interestingly, in vitro tyrosine kinase assay, dasatinib directly inhibited the activities of Lyn and Fyn, the upstream tyrosine kinases of Syk in MCs. Taken together, dasatinib suppresses MCs and PCA in vitro and in vivo through the inhibition of Lyn and Fyn Src-family kinases. Therefore, we suggest the possibility of repositioning the anti-cancer drug dasatinib as a treatment for various MC-mediated type I hypersensitive diseases.